In Montana:

  • As of July 1, 2011, there were 106,493 beneficiaries enrolled in Montana’s Medicaid program. Of these, 81,085 were enrolled in the state’s primary care case management program.
  • Children are required to enroll a primary care case management program, Passport to Health. Passport to Health covers a number of services, including EPSDT, inpatient and outpatient mental health, and substance use disorder treatment. Magellan Medicaid Administration provides utilization Management services to the state for mental health benefits (including for children).
  • Children with a Serious Emotional Disturbance qualify for services under the state’s 1915(i) State Plan Home and Community Based Services. The state also has 1915(c) home and community-based service waivers that impact children, including:
    • A bridge waiver to continue serving youth who were enrolled in a Psychiatric Residential Treatment Facility on the last day of a demonstration that ended in late 2012, and
    • A children’s autism waiver.

As of 2012, 89,485 individuals were eligible for Montana Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. According to CMS data from 2012, Montana achieved an EPSDT screening ratio of 100% and a participation ratio of 59%. 35,919 children received dental services of any kind, with 31,824 receiving preventive dental services.

Last updated May 2014

Medical Necessity
Regulations in Montana define a medical necessary service as:
“ a service or item reimbursable under the Montana Medicaid program, as provided in these rules:
  • Which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions in a patient which:
    • endanger life;
    • cause suffering or pain;
    • result in illness or infirmity;
    • threaten to cause or aggravate a handicap; or
    • cause physical deformity or malfunction.
  • A service or item is not medically necessary if there is another service or item for the recipient that is equally safe and effective and substantially less costly including, when appropriate, no treatment at all.
  • Experimental services or services which are generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of the Montana Medicaid program.
    • Experimental services are procedures and items, including prescribed drugs, considered experimental or investigational by the U.S. Department of Health and Human Services, including the Medicare program, or the department’s designated review organization or procedures and items approved by the U.S. Department of Health and Human Services for use only in controlled studies to determine the effectiveness of such services.”
Initiatives to Improve Access
Medicaid-enrolled children (as well as other children) in Montana have access to Pediatric Specialty Clinics sponsored by Children’s Special Health Services in the Montana Department of Public Health and Human Services.
Reporting & Data Collection

Behavioral Health
In Montana, Magellan Medicaid Administration provides utilization Management services to the state for mental health benefits (including for children). The Children’s Mental Health Services Bureau in Montana’s Department of Public Health and Human Services has produced a Provider Manual and Clinical Guidelines for Utilization Management as it pertains to mental health services provided to Medicaid-enrolled children.
Montana’s Medicaid provider manual specifies that each well-child visit should include an age-appropriate developmental screen. Risk assessment screenings for “signs and symptoms of emotional disturbances” as well as risky behaviors (including substance abuse).

Montana’s 1915(i) State Plan Home and Community-Based Services are available to children with a Serious Emotional Disturbance (SED). The state has created a brochure for families of children with SED advertising the availability of:

  • wraparound facilitation
  • peer to peer support for youth and parent
  • in-home therapy
  • respite
  • crisis intervention services
  • specialized evaluation services
  • supplemental supportive services
  • additional services designed to help the youth remain at home and in the community
A more detailed Policy Manual on 1915(i) services for children with SED provides more information on the services available and eligibility requirements for children and providers.
Support to Providers and Families
Support to Families

Montana Medicaid has produced a Member Guide that covers available services, including a description of the components of a well child visit, included immunizations, and the recommended schedule for well child visits. The state has also produced a video on well-child checkups. Fliers advertising EPSDT services are also available for families.

Support to Providers
Montana Medicaid offers a number of provider manuals and bulletins. The state also makes available a variety of resources for providers, including on children’s mental health services and oral health services.
Care Coordination
Montana’s Passport to Health primary care case management program is intended to promote the medical home model and better coordinate care for Medicaid enrollees.
Montana also has a Health Improvement Program that provides more intense coordination and care management of high-risk, high-cost Medicaid beneficiaries. The program works with patients’ primary care providers to develop a holistic treatment plan, and it builds partnerships with a range of medical and non-medical (e.g., social service) resources to help coordinate care and manage each patient’s conditions.
Oral Health
Montana’s Department of Public Health and Human Services provides resources on oral health services in the state. This includes a list of providers treating Medicaid-enrolled children, a Medicaid dental fact sheet on How to Find and Keep a Dentist, and rules and fees for orthodontia services for Medicaid beneficiaries under age 21. The state also provides a list of federally funded health center dental clinics.
Montana also has several brochures on Medicaid dental services for families and children on its oral health program website, as well as resources on school-based oral health screenings.